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THE GREAT DEBATE |
From Medscape, New York, NY.
Address reprint requests to: George Lundberg, MD, Editor-in-Chief, Medscape, 224 West 30th Street, Medscape 5th Floor, New York, NY 10001. Email: GLundberg{at}medscapeinc.com
Dr. Markovitz, fellow panelists, fellow interested participants, fellow listeners. I appreciate the opportunity to be the discussant in this interesting debate. I found it a fascinating morning, one of high intellect, high feelings, reasonable civility, and near agreement on much we all want—good science— if we could figure out how we can agree on exactly what that is. When I was first contacted about this program, I was told that the organizing committee needed someone as a discussant who was perceived as unbiased in a field characterized in large part by bias, and that I had a reputation of objectivity. I was flattered, obviously, and of course I agreed to participate. Thank you for the opportunity.
My secret weapon in this subject and my self-declared reason for being (in fact, unbiased) is that I know virtually nothing about the subject, so I am a particularly good candidate to be the discussant. One of the secrets for my successes in 17 years at Journal of the American Medical Association was that I tried very hard not to write about something I did not know anything about, regardless of the temptation or the opportunity; and there were many of both of those. When I would take editorial positions on a subject, I always tried to tie the editorial position to a base of hard data. I was perfectly happy to go beyond the data ethically, morally, etc, in a transparent way, but I hoped always to begin with hard data.
Disclosure is very important. I have two disclosures to make here in addition to my statement that I profess to know little about the topic. Dr. Relman, Dr. Angell, and I met at lunch in Boston in 1982. For a number of years we were natural competitors, generally in a civil manner. Later we were colleagues in international editing circles "big time" as W. might say. Later, we became friends in a very real sense, having been through a lot of similar wars together, although we were 1000 miles apart geographically for most of that time. On another side, as Jerry mentioned, I hold two graduate degrees at University of Alabama Birmingham, from which Dr. Markovitz currently hails; and the old saying that "You can take a boy out of Alabama, but you can never take Alabama out of a boy" is very true and a major source of deepest feelings for me that I fundamentally cannot control.
I have a mind (I think), I have a body, I happen to believe I also have a soul; and I believe they are all connected. I am a pathologist. I have performed or supervised thousands of autopsies. The brain is a big organ. It is up here in the skull, but there are a lot of very elaborate connectors, which anatomically run between various parts of the brain and all sorts of the rest of the body. I do not believe those connectors are there by chance. I think there are reasons, some of which we understand clearly, like "I choose to move my finger, so I move it," some of which we understand less clearly, like "if I massage the bottom of my foot by running a certain amount, I might feel really good because of chemicals like endorphins" or "If I smell a certain fragrance or see a certain form I might be quickly capable of the biological physiological fact of race preservation by efforts at procreation." And some connections I don’t understand at all, and thus, must fundamentally doubt their validity. I have to doubt their validity if I cannot understand them (I guess that follows), like mentally willing that a biopsy-proven prostate cancer go bye-bye. No, I do not think so.
Alas, of course, in all those human dissections, I never found a soul. Souls exist in faith, and Saint Paul best said (and I think this is applicable for today’s conversation significantly) that, "faith is the substance of things hoped for, and the evidence of things not seen." I suppose stress might be a center point in the discussion to the importance of whether "psychosocial interactions can improve clinical outcomes in organic diseases." This week, I was in a cab on Monday afternoon on my way from Union Station in Washington DC to a hotel before celebrating the 10th anniversary of the National Committee for Quality Assurance that evening, and we went past George Washington Medical Center in Foggy Bottom, and almost the entire block was lined with a lot of TV cameras and backup equipment. When I asked my cab driver what was going on, he said, "The Vice President has had another heart attack." The New York Times reported that there was a question directed to the esteemed cardiologist Dr. Eugene Braunwald as to whether Mr. Cheney’s chest pain (brought on (we were told) by myocardial ischemia (we were told) by scar tissue compressing the distal tip of a coronary artery stint) was brought on by the stress of him (for all intents and purposes other than ceremony) being the "President of the United States." It further asked Dr. Braunwald whether Mr. Cheney should step down to preserve his life? Dr. Braunwald is reported to have said that stress had nothing whatsoever to do with the scar tissue episode; that people respond to stress in very different ways and it was the VP’s decision whether to stay at work or choose to do something else. That, of course, is quintessential patient autonomy, which is at a really big-time now in 2001.
The first lecture I ever heard about stress was during medical school in Birmingham, from Hans Selye from the University of Montreal. I think he may have created the concept of stress. My memory is vivid from that day; he had a wonderful French accent, a glorious gentlemanly type. He was treated with enormous respect by the faculty at UAB, such as it was back in those early days. I remember Joe McManus, who was my professor of pathology, arguing with someone saying "yeah, but that is entirely academic" and he said "yeah, but this is an academy—of sorts." Selye said that stress was everywhere, it affected all kinds of bodily functions in major ways and that different people responded very differently. That was in 1955, and I think that is about where we are (no offense intended) in 2001.
I hate combination words. They confuse, confound, and allow complete escape points; and I will use such an escape point at this moment. Today we are assigned "psychosocial interventions," hmmm. I am reminded of the day in 1982 when I convened my first JAMA editorial board meeting. My staff and I had developed a set of goals for JAMA, and we sought consultation and possible approval from the editorial board. The goals were ultimately published as goals for the Journal in August 1982 and sstarted us on our many years of success. One of the goals included a word called "socioeconomic." Dr. Angell used that word a little earlier this morning. Renee Fox, a great University of Pennsylvania sociologist, was a member of my editorial board at that time. She objected strenuously; she said "that is two words, not one word." Economics is economics and social is social. I am a sociologist, do not put them together. Well, I said obediently "yes maam" and I have never uttered or written (to my recollection), "socioeconomic" again. I would suggest that you not do so either, because they are different. Today, we have "psychosocial," and I would suggest they are different. "Psycho" refers to psychotherapy, psychology, psychiatry; and "social" refers to sociologic or social, and of course they are related, but I think they are quite different, so I will divide the issue.
Does a successful social intervention to prevent tobacco use in a tobacco addict improve the clinical outcome of recognized coronary disease or chronic obstructive pulmonary disease? The answer is absolutely yes, often. Does a psychologic intervention in metastatic pancreatic carcinoma improve clinical outcome. I would say "what outcome are you talking about?" If it is length of life, I would say no. If it is quality of adaptation to being in a state of terminal illness? Quite likely, yes. Comfort? Absolutely yes. Might that comfort level prevent suicide in that patient as a method of shortening life? Well, yes, it might. On the other hand it might promote it, I am not sure. Can social marketing utilizing psychological principles help prevent SIDS in babies? Absolutely. Procter & Gamble has placed the words "Back to Sleep" on the front of their disposable diapers to teach young mothers to put babies to sleep on their backs—not on their tummies, thereby preventing sudden-infant death syndrome in babies. Efforts like these have produced a 70% decrease in SIDS deaths. These were social interventions based on psychological efforts with epidemiological data to support them, published in many other countries until one journal in this country was willing to take a chance on it, and it was, of course, JAMA. I am convinced that many social interventions with psychological roots can affect diseases by primary prevention, are probably helpful in secondary prevention, and may be helpful in treating some chronic diseases as well. For example, I believe that one can psychologically and socially grow old, or psychologically and socially not grow so old, at the same age. Is aging a chronic organic disease? Yes, it is. It is 100% fatal. On the other hand, is it a disease at all? I do not know. If disease is something not normal, then I say no, since it is also 100% normal.
My favorite study in this field, and not included in this very interesting packet of information, is from JAMA (1). I accepted this paper while still editor and it was published on April 14, 1999. It was by a Dr. Smyth from SUNY Stonybrook. It was about the effect of writing about one’s own traumatic experiences on symptoms of rheumatoid arthritis and asthma. Now, are symptoms outcomes? Yes, they are. Are rheumatoid arthritis and asthma chronic diseases and organic in nature? Yes, they are. The study was a randomized, controlled, clinical trial with sufficient numbers for statistical power (statistically and epidemiologically reviewed up the kazoo) before publication. Such intervention showed a positive, helpful effect. People who had aired on paper their bad experiences, verbalizing them to no one, not necessarily read by anyone, not discussed, no psychotherapy, no group therapy, no feedback, just writing it down. Those who did so had significantly fewer symptoms.
Maybe we should bring back daily diaries. It sounds like a good thing for people to do, write about how you feel. I know, I am a writer myself, and when I have experienced something really bad, I sometimes sit down and write about it even if nobody else ever reads it (a lot of times it is better that no one ever read it), and I feel a lot better. That brings us from science to anecdote.
After science we have anecdote. Anecdote is not science, but it is powerful when it is experienced individually, as I have just described. The gold standard that Dr. Markovitz has asked me to describe is the randomized controlled, prospective, clinical trial with blinding, with large enough numbers without confounders, to provide statistical power, said trials performed by researchers without conflicts of interest be they financial or otherwise. Since there are no people without conflicts of interest, full disclosure of those conflicts to the editors and the readers is essential. One should rely on articles published in good journals after a comprehensive review and revision process performed by editors and reviewers without bias or with balanced, considered, and disclosed biases. I can assure you that editors are full of biases; gender biases, age biases, geographic biases, school biases, discipline biases, race biases, and culture biases. And lots of times editors are sitting around a table and say, "are we going to publish this or not?" and it goes back and forth and back and forth. I mean, the Blockbuster paper—that is easy, and the terrible paper—that is easy, but for many of the papers, it is not so sure and then all these biases do come into play.
Generally, one needs more than one carefully controlled clinical trial, and if you have them and they all meet the criteria I indicated, they still often disagree. I believe in meta-analyses, but I only believe in putting published studies in them (although there is bias there also) because of the negative/positive publication bias thing, and people deep-sixing their own stuff if it does not show a positive effect. And I would only include good studies in meta-analyses.
Finally, in November 1998, we at the AMA published about 80 articles on alternative medicine in 10 journals all at once. In our editorial, Phil Fontanarosa and I wrote that there is no "alternative medicine," there is only medicine (2). Medicine that has been tested and found to be safe and effective; use it, pay for it. Medicine that has been tested and found to be not effective and not safe; do not use it and do not pay for it. Medicine that has not been tested but has some plausible reason to be possible (not preposterous, not impossible by laws of physics, etc, but some kind of sensible reason). Test it and put it into one of those first two piles. I suppose I would apply the same criteria to the fields of social and psychological intervention. Keep these investigations going. Make the science as rigorous as it can be. Then we should all agree to live with and practice based on the results of what we always want, a level playing field. Thank you very much.
Received for publication September 10, 2001.
Revision received September 27, 2001.
REFERENCES
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  N. Schneiderman and R. B. Williams THE GREAT DEBATE EDITORIAL, REVISITED Psychosom Med, July 1, 2006; 68(4): 636 - 638. [Full Text] [PDF]
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K. E. Freedland, G. E. Miller, and D. S. Sheps The Great Debate, revisited. Psychosom Med, March 1, 2006; 68(2): 179 - 184. [Full Text] [PDF]
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